A traumatic brain injury (TBI) is as catastrophic as it sounds. It occurs when the brain is struck or jolted from outside forces and often has several debilitating repercussions. According to the Brain Injury Association of America (BIA), at least 5.3 million Americans – or 1-in-every-60 – live with a TBI-related disability. But even that statistic might not provide the full scope of the condition in the U.S.; the BIA estimates that at least 2.8 million people sustain a TBI each year, but it is unknown how many of those people actually seek treatment.
When an injured person sustains a mild, moderate, or severe TBI, they should see a physician and neurologist. These medical professionals will create a long-term or a life care plan to help the injured person and their family to navigate the uncertainties.
Why TBI Victims Need A Life Care Plan
A Life Care Plan is a document issued by a physician. It is based on published standards of practice, comprehensive assessment, data analysis and research. This organized, concise strategy itemizes and projects the costs for current and future needs and services. For example, the life care plan will detail whether you need:
- Day treatment. Four to six hours per day, five days per week, of allied health services for cognitive, physical, and speech related deficits.
- Outpatient treatment. Up to three hours per day, one to five days per week.
- Home and Community-Based Treatment. These services rose in popularity since 2020 due to the pandemic, as they are provided in an individual’s home and/or community settings.
Certain TBIs, including those that result in a coma/disorders of consciousness state, require much more time to treat, but that doesn’t mean that hope should fade. Long-term skilled care is the best option for TBI victims who are medically stable, but require intensive nursing, therapy and/or medical support that may not be available in other settings.
An accurate plan will ultimately improve the clinical state of the patient and support their families by providing a disability management program. This will help prevent unnecessary complications and minimize the patient’s long-term care needs.
Understanding Insurance Coverage Limits
When it comes to TBI, the insurance process can be a bit of a labyrinth. For example, most insurance companies view brain injuries as a medical condition. But there are currently no federal mandates requiring health insurance plans to cover specific brain injury services.
That is why healthcare insurance plans vary on what they will and will not cover. For example, indemnity or “traditional” insurance is more costly than other types, but also offers greater choice of doctors and hospitals.
Managed care plans are more limited in coverage and benefits, but establish quality measures and program guidelines. Common managed care plans include Preferred Provider Organization (PPO) and Exclusive Provider Organization (EPO) plans.
If you disagree with your insurer’s assessments and recommendations following a loved one’s TBI, for example, it may require some back-and-forth to trigger the appropriate benefits. You can attempt to communicate and negotiate with the insurance company or seek a legal advocate to help secure your benefits.
HOW CAN A LAWYER HELP ME?
Severe trauma to the brain can result in decreased cognitive function, changes in behavior or personality, loss of motor skills, language difficulties, memory loss, or even death.
Too often, insurance companies try to find ways to deny an injured claimant or compensate them much less than they deserve. In order to ensure that you secure the maximum coverage from your insurance plan, contact an experienced lawyer who understands TBIs, knows what your insurance policy covers, and will negotiate.
If you or your loved one suffers from TBI, contact our Los Angeles insurance lawyers at ACTS Law. We can review your life care plan and help you receive maximum benefits from your insurance company in an effort to help you live as comfortably as possible. To schedule a free, confidential consultation, call us today at 833-ACTS-LAWopens phone dialer or contact us online. With offices located in Los Angeles and San Diego, we serve clients throughout Southern California.